Community Neuro Specialist Nurse

Job overview

The post holder will develop, implement and evaluate a seamless community MS/PD specialist service ensuring that patients receive the highest standard of clinical care and that specialist advice, education and support to health professionals and patients is provided. The post holder will drive service development, audits and research within the Community Neuro service. They will have highly developed clinical expertise enabling them to plan, deliver and co-ordinate complex care in routine and non-routine circumstances to ensure that the needs of the person with MS/PD are best served.

They will work collaboratively with the established Primary Care Networks, ensuring cohesive leadership across the three localities and they will be link with the upcoming Neighbourhood Health Hubs.

The post holder will be an integral part of the West Essex Neighbourhood model, working in partnership with other stakeholders to meet the needs of the local population using public health information/population management to support service development. In addition they will work closely with the Virtual Hospital and Care Co-ordination Centre (CCC) to prevent hospital admission, facilitate hospital discharges and ensure care is delivered in the right place at the right time.

The main focus will be on integration to ensure the service is of the highest quality, by supporting the Neighbourhood Operational Leads in implementing and monitoring the clinical and management strategy for the service.

Main duties of the job

• Work jointly with the acute MS/PD team to contribute to a seamless service for patient's
• Function autonomously in an adept manner to assess, manage, plan and implement treatment tailored to individual patients across the PD/MS disease spectrum in both routine and non-routine circumstances.
• Demonstrate an equitable service through audit and clinical effectiveness
• Employ a collaborative approach with the wider multidisciplinary team to ensure care for patients and their families is effectively coordinated and their needs are met.
• Continually develop and update knowledge and highly specialist skills to maintain specialist competence and ensure delivery of evidence based care
• Maintain the MS/PD patient caseload including acceptance of appropriate referrals, triage, waiting times and discharging patients to a dormant caseload when active input is no longer required
• To develop, deliver and evaluate a plan of care relating to symptom management, which will include assessment, planning, implementing, reviewing and documenting care plans in agreement with the person with MS/PD. This will include but not exhaustive of ordering diagnostic tests and making referrals.

Detailed job description and main responsibilities

• Work jointly with the acute MS/PD team to contribute to a seamless service for patients.
• Function autonomously in an adept manner to assess, manage, plan and implement treatment tailored to individual patients across the PD/MS disease spectrum in both routine and non-routine circumstances.
• Demonstrate an equitable service through audit and clinical effectiveness
• Employ a collaborative approach with the wider multidisciplinary team to ensure care for patients and their families is effectively coordinated and their needs are met.
• Continually develop and update knowledge and highly specialist skills to maintain specialist competence and ensure delivery of evidence based care.
• Develop and maintain current knowledge, skills and competence to ensure delivery of evidence based care.
• To be professionally accountable and responsible for all aspects of own work, including the management of own caseload.
• Maintain the MS/PD patient caseload including acceptance of appropriate referrals, triage, waiting times and discharging patients to a dormant caseload when active input is no longer required
• To develop, deliver and evaluate a plan of care relating to symptom management, which will include assessment, planning, implementing, reviewing and documenting care plans in agreement with the person with MS/PD. This will include but not exhaustive of ordering diagnostic tests and making referrals.
• Design and deliver education and self-management courses to people with MS and their families. Provide specialist education to other professionals involved in the care of people with MS/PD
• Provide care in a timely manner in line with local and national protocols and guidance.
• Support and facilitate patients to self-manage their disease ensuring they know when to seek help.
• Have awareness of the resources available and the need to work within the financial envelope.
• Actively participate in service development.
• Active involvement in a multidisciplinary approach to the decision making process regarding commencing disease modifying treatment. Participate in ongoing delivery of treatment and monitoring of patients while on treatment
• Provides and receives highly complex, sensitive and potentially distressing information.
• Overcomes barriers to understanding, such as stress or poor cognition, demonstrating empathy and reassurance.
• Communicates openly and appropriately with patients and carers in situations of highly distressing or sensitive nature, such as discussions with the person with MS and their family around end of life care matters.
• To actively involve service users in providing feedback of their experience of the current service and suggestions for improvements.
• To contribute positively to the leadership within the care group acting as an effective role model.